Medication Chart



|MED LIST |[pic] | |

|Information About You | |Questions to Ask Your Doctor |

|Name _____ | | |

|Address _____ | | |

|Birth Date Blood Type Weight Height_____________ | | |

|Pharmacy ____ Phone _____ | | |

|Primary Care Physician__________________________ Phone____ _____ | | |

|Other Physicians ____ Phone _____ | | |

|or Specialists ____ Phone _____ | | |

|Emergency Contact ____ Phone _____ | | |

| | | |

|Medical Conditions | |Vaccinations (please note the date of the immunization) |

| Asthma Heart Disease Diabetes High Blood Pressure | |Influenza Pneumococcal |

|Cancer Kidney Disease Other _____ | |MMR Tetanus/Diphtheria |

| | | |

|Important Health Care Documents | |Health Insurance Plans |

| |Location of Document | | |

| | | | |

| | | | |

| | | | |

| Health Care Proxy | | | |

| Health Care Durable Power of Attorney | | | |

| Interested in Organ or Tissue Donation | | | |

| | | |

|Over-the-Counter Medications and Other Supplements | |Discontinued Medications/Products (due to Allergies, Side Effects, or Reactions) |

| | | |Medication/Food/Environment |

|Allergy |Diet Pills | |that cause a reaction |

|Relief/Antihistamines |Vitamins and Minerals | |Allergy, Side Effects, Reaction or |

|Cough/Cold Medications |Herbal/Dietary | |Intolerance Experienced (symptoms, severity) |

|Aspirin/Other |Supplements | |Date (mm/yy) |

|for Pain/Headache/ Fever |St. John’s Wort | | |

|Antacids |Gingko Biloba | | |

|Laxatives |Kava Kava | | |

|Sleeping Pills |Other (be sure to list | | |

| |on other side) | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

Massachusetts Coalition for the Prevention of Medical Errors ( Betsy Lehman Center for Patient Safety and Medical Error Reduction ( Massachusetts Medical Society

MEDICATIONS Please use pencil to complete this form. Patient Name

Start Date |Name of Medication |Prescribed By |Dosage |When is the Medication Taken |Purpose |Danger Signs* |Stop Date |Monitoring Required |Notes/ Changes | |mm/dd/yy |Brand and Generic name (If available) | |mg/ units/ puffs/ drops |How many times per day? Morning and/or night? After meals? | |Call Immediately if you experience any of these signs |mm/dd/yy |e.g. lab test every ___ weeks |Patient Have you experienced any side effects? If stopped taking, why? Doctor Identify drugs and/or food that may cause interactions. Date list was reviewed/updated | |1/01/06 |Medication ABC |Dr. ABC |5 mg |2 times, morning and night |Ulcer | | |Blood Test Every 4 weeks |6/15/06 – Reviewed by Dr. ABC, Changed Dosage to 10mg | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |

* Always refer to physician and pharmacist input and the detailed drug sheets provided with each medication for a complete list of potential side effects/danger signs/interactions. Whenever you see a doctor, including your primary care physician and any specialists, review and update this medication list. After any hospitalization, check with your doctor to review this medication list.

Massachusetts Coalition for the Prevention of Medical Errors • Betsy Lehman Center for Patient Safety and Medical Error Reduction • Massachusetts Medical Society

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download